Office of the Registrar Attn: Joyce Oestrike 1555 South Raisinville Road Monroe, Michigan 48161
Phone: 734.384.4108 Fax: 734.384.4170 Email: joestrike@monroeccc.edu
Enrollment Certification Request Complete this application in its entirety. Failure to submit a complete application each semester will delay the processing of your VA certification to the Department of Veteran Affairs. In addition, if you have not done so, submit any appropriate documentation (DD-214, parent letter).
Student Information Student Information Last name: ______________________________ First name: ___________________ MI: ________ MCCC Student ID #: ______________________ Birth Date: ____________________ MCCC Email: ____________________________________ Contact Number: (____) ______-______ DegreeStudent and Major Information Information Degree/Certificate: ____________________________________________________ Major: _________________________________ Select One:
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New Student: (I have never used my VA Education Benefits and have not attended any university/college since high school)
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Guest Students: My parent school is: ______________________________________*MUST submit a parent school letter from the VA Certifying Official.
Returning Student: Select One:
¨ I have never used my VA Education Benefits ¨ I have previously used my VA Education Benefits at MCCC
Continuing: (Previous VA Certified at MCCC) Transfer Student: Select One:
Currently Active Duty Military?
¨ I have never used my VA Education Benefits ¨ I have previously used my VA Education Benefits at _______________________________________________________
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Yes
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No
Education Program Information Student Information Please check GI Bill Benefit election:
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Chapter 30, 1606, and 1607 must verify attendance to the VA each month online at www.gibill.va.gov/wave or by telephone at (877) 823-2378
Chapter 30
Montgomery GI Bill - Active Duty
Chapter 1606
Montgomery GI Bill - Selected Reserves
Chapter 1607
Reserve Educational Assistance Program (REAP)
Chapter 33
Post 9/11 GI Bill - Entitlement Percent _____________________________
Chapter 35
Survivor’s & Dependent’s Assistance - VA File Number: _______________
Semester:
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Fall
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Winter
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Spring
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Summer
Total Number of Credits: _________________
Read and Sign Student Information l I understand that it is my responsibility to report any status changes (including add/drops, withdrawals, address changes, change of major or any other changes that may affect my entitlement to GI Bill benefits.) I also understand that these changes could create a debt with the VA. l I understand that I am responsible for any debt owed to Monroe County Community College or Veteran Affairs resulting from an overpayment in my education benefits. Non-payment may affect my student account and future registration. l I, the undersigned, certify that the above statements are true to the best of my knowledge. I have read and understand my responsibilities as outlined above. I will report any and all status changes to the School Certifying Official as soon as they occur. Signature: ___________________________________________________________ Date: ____________________ Certifying Official ONLY
_____________________________ Certification ID #: _____________________________ Enrollment Dates:
_______________________________ Date Processed: ________________________________ Tuition and Fees: